Cited by 12Patient Safety and Medication ErrorsMaternal and Perinatal Health InterventionsSurgical site infection prevention

Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery

Open access
Combs, C. Andrew, Einerson, Brett D., Toner, Lorraine E.·2021·American Journal of Obstetrics and Gynecology

Abstract

Cesarean delivery is a surgical procedure that involves delivering a baby through an abdominal incision (laparotomy) and a uterine incision (hysterotomy). This StatPearls reference details the indications, contraindications, surgical personnel, preparation, technique, complications, and clinical significance of cesarean birth.

Integrity signals

Registry

Crossref · 10.1016/j.ajog.2021.07.011

Cites

21 of 21 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

5 of 19 cited sources checked · 3 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Routine use of surgical safety checklists can reduce perioperative complications.

    “The routine use of surgical safety checklists can reduce perioperative complications.”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [3] 3. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9. source
    • cites [4] 4. de Vries EN, Prins HA, Crolla RM, et al. Effect of a comprehensive sur- gical safety system on patient outcomes. N Engl J Med 2010;363: 1928-37. source
  • Premisecitation

    Surgical safety checklists have been shown to reduce serious perioperative complications and death by 30% to 40% when implemented across a wide range of hospital settings.

    “Surgical safety checklists, such as the one developed by the World Health Organization (WHO), 2 have been shown to reduce serious perioperative complications and death by 30% to 40% when implemented across a wide range of hospital settings.3,4”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [3] 3. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9. source
    • cites [4] 4. de Vries EN, Prins HA, Crolla RM, et al. Effect of a comprehensive sur- gical safety system on patient outcomes. N Engl J Med 2010;363: 1928-37. source
  • Premisecitation

    Studies demonstrating reduced morbidity and mortality with the use of a surgical safety checklist include detailed implementation programs involving extensive staff engagement and education.

    “Studies demonstrating reduced morbidity and mortality with the use of a surgical safety checklist include detailed implementation programs involving extensive staff engagement and education.3,4,9”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [3] 3. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9. source
    • cites [4] 4. de Vries EN, Prins HA, Crolla RM, et al. Effect of a comprehensive sur- gical safety system on patient outcomes. N Engl J Med 2010;363: 1928-37. source
    • cites [9] 9. Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. Intro- duction of surgical safety checklists in Ontario, Canada. N Engl J Med 2014;370:1029-38. source
  • Premisecitation

    Active steps to maintain normothermia are supported by high-quality evidence.

    “Active steps to maintain normothermia are supported by highquality evidence.19”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [19] 19. Sultan P, Habib AS, Cho Y, Carvalho B. The Effect of patient warming during caesarean delivery on maternal and neonatal outcomes: a meta- analysis. Br J Anaesth 2015;115:500-10. source

      The Discussion recommends active warming for elective Caesarean delivery to reduce maternal temperature decreases, hypothermia, and shivering (page not available in our copy). It does not characterize the evidence as high-quality; it notes significant heterogeneity and possible publication bias. The claim also omits the elective-Caesarean-delivery setting to which the recommendation applies. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
  • Premisecitation

    Pausing to identify the patient and planned surgical procedure reduces the chances of wrong-patient, wrong-site, or wrong-procedure operations and other 'never events.'

    “Pausing to identify the patient and planned surgical procedure reduces the chances of wrong-patient, wrong-site, or wrongprocedure operations and other”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [5] 5. Mohammed A, Wu J, Biggs T, et al. Does use of a World Health Or- ganization obstetric safe surgery checklist improve communication be- tween obstetricians and anaesthetists? A retrospective study of 389 caesarean sections. BJOG 2013;120:644-8. source
  • Classified as probably not a substantial claim. 12
  • May combine two claims. 7
  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    The implementation of a surgical safety checklist is a complex and challenging process that requires effective leadership, clear delegation of responsibilities from each professional, collaboration between team members, and institutional support.

    “A recent review concluded that the implementation of a surgical safety checklist is”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [13] 13. Gillespie BM, Marshall A. Implementation of safety checklists in sur- gery: a realist synthesis of evidence. Implement Sci 2015;10:137. source

      The Results (Interaction of contexts and causal mechanisms on implementation and sustainment; page unavailable) identify active leadership, team participation, and organisational climate as factors in checklist implementation. The Results (Explanatory model; page unavailable) also describe implementation challenges and the need for senior-leader support. Our copy does not establish clear delegation of responsibilities to each professional as a requirement. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
  • May combine two claims.

    Findingcitation

    The authors found only 2 published examples of a specific surgical safety checklist for cesarean delivery, neither of which includes a dedicated newborn care provider.

    “Although we are aware that some hospitals have developed a specific surgical safety checklist for cesarean delivery, we have only found 2 published examples, neither of which includes a dedicated newborn care provider.6,7”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [6] 6. Sun M, Patauli D, Bernstein PS, Goffman D, Nathan LM. Use of a ce- sarean delivery checklist in an African maternity ward to improve man- agement and reduce length of hospital stay y . Int J Gynaecol Obstet 2021;152:236-41. source
    • cites [7] 7. Committee Opinion No. 680: the use and development of checklists in obstetrics and gynecology. Obstet Gynecol 2016;128:e237-40.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Roughly one-third of sentinel events reported to The Joint Commission in recent years involve surgery or anesthesia.

    “Therefore, it is not surprising that roughly one-third of sentinel events reported to The Joint Commission in recent years involve surgery or anesthesia. 1”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1] 1. The Joint Commission. Summary data of sentinel events reviewed by The Joint Commission. Available at: https://www.jointcommission.org/-/ media/tjc/documents/resources/patient-safety-topics/sentinel-event/ summary-se-report-2020.pdf. Accessed August 5, 2021.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

    Interpretationreasoning

    Attention to these implementation steps should increase engagement of all users and increase the rate of utilization, thereby improving the rate of completion of the many critical steps that contribute to a safe cesarean delivery.

    “Attention to these implementation steps should increase engagement of all users and increase the rate of utilization, thereby improving the rate of completion of the many critical steps that contribute to a safe cesarean delivery.”
    Quote in the paperNot a substantial claim
  • May combine two claims.

    Interpretationreasoning

    In cases of time-critical emergency cesarean delivery, there is no time to complete the preoperative checklist or the standard cesarean delivery safety checklist.

    “In such cases, there is no time to complete the preoperative checklist (Box 3) or the standard cesarean delivery safety checklist (Boxes 1 and 2).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: In a small percentage of cases, a time-critical emergency necessitates that a surgery must start without delay.
  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    The sustained use of surgical checklists is discipline specific and is more successful when physicians are actively engaged and leading implementation.

    “Another review concluded that”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [14] 14. Society for Maternal-Fetal Medicine (SMFM), Bernstein PS, Combs CA, et al. The development and implementation of checklists in obstetrics. Am J Obstet Gynecol 2017;217:B2-6.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim.

    Premisecitation

    It is not the act of ticking off a checklist that reduces complications, but performance of the actions it calls for.

    “Commenting on that failure, Leape 11 wrote,”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [11] 11. Conley DM, Singer SJ, Edmondson L, Berry WR, Gawande AA. Effective surgical safety checklist implementation. J Am Coll Surg 2011;212:873-9. source
  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    If general anesthesia is to be used or the patient is heavily sedated, the patient will be unable to participate in the safety checklist, so other team members will need to check wristbands against the paperwork and the stated planned procedure.

    “If general anesthesia is to be used or the patient is heavily sedated, the patient will be unable to participate, so other team members will need to check wristbands against the paperwork and the stated planned procedure.”
    Quote in the paperNot a substantial claim
  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Some hospitals include chlorhexidine shower and chlorhexidine wipes as part of enhanced recovery after surgery bundles.

    “One example is the use of a chlorhexidine shower and chlorhexidine wipes in the preoperative checklist (Box 3); some hospitals include these procedures as part of enhanced recovery after surgery bundles.18”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [18] 18. Caughey AB, Wood SL, Macones GA, et al. Guidelines for intraoperative care in cesarean delivery: enhanced recovery after surgery society recommendations (Part 2). Am J Obstet Gynecol 2018;219: 533-44.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Additional coordination and communication are needed to ensure the safety of both patients in cesarean delivery.

    “Thus, additional coordination and communication are needed to ensure the safety of both patients.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Cesarean delivery involves 2 patients (the mother and the fetus or newborn), each with separate care teams and health and safety considerations.
  • Classified as probably not a substantial claim.

    Interpretationreasoning

    It is not sufficient to simply post a checklist and tell providers to use it.

    “It is not sufficient to simply post a checklist and tell providers to use it.”
    Quote in the paperSubstantial claim
  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    These rehearsals will teach the team how easy or difficult it is for people with minimal training to use the materials.

    “These rehearsals will teach the team how easy or difficult it is for people with minimal training to use the materials.”
    Quote in the paperNot a substantial claim
  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Hospitals may use different means to accomplish normothermia, including forced-air warming devices, underpatient warming devices, warming of intravenous fluids, or increasing ambient temperature of the operating room.

    “However, hospitals may use different means to accomplish this, including forced-air warming devices, underpatient warming devices, warming of intravenous fluids, or increasing ambient temperature of the operating room.19e21”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites 19e21

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    The question-answer format of the larger sample checklist is intended to guide providers to double-check each other's work, encourage dialog, and keep all individuals engaged throughout the process.

    “In the larger sample checklist (Box 1), most items are written as questions for a designated team member to ask other team members.This format is intended to guide providers to double-check each other's work, encourage dialog, and keep all individuals engaged throughout the process.”
    Quote in the paperNot a substantial claim
14 of 14
  • The paper relies on this without support.

    Cesarean delivery involves 2 patients (the mother and the fetus or newborn), each with separate care teams and health and safety considerations.

    “Generic surgical safety checklists are insufficient for cesarean delivery because each cesarean delivery involves 2 patients (the mother and the fetus or newborn), each with separate care teams and health and safety considerations.”
    “Cesarean delivery is even more complex than other types of surgical procedure because there are 2 patients (the mother and the fetus or newborn), each with separate care teams and health and safety considerations.”
  • The paper relies on this without support.

    In many hospitals, the items on the preoperative checklist are scattered across various formats, including paper forms, electronic health records, tablet computer applications, and fetal heart monitoring systems.

    “In many hospitals, the items on this checklist are scattered across various formats, including paper forms, electronic health records (EHRs), tablet computer applications, and fetal heart monitoring systems.”
  • The paper relies on this without support.

    In a small percentage of cases, a time-critical emergency necessitates that a surgery must start without delay.

    “In a small percentage of cases, a time-critical emergency necessitates that a surgery must start without delay.”
  • The paper relies on this without support.

    In most cases, the emergency will have been resolved by the time of closing.

    “In most cases, the emergency will have been resolved by the time of closing; therefore, we recommend performing the full debriefing section of the standard cesarean delivery safety checklist in addition to a few items unique to emergency cases (eg, x-ray to rule out retained materials and a reminder to place sequential compression devices postoperatively to prevent venous thromboembolism).”
  • The paper relies on this without support.

    Use of a checklist reduces the chance of neglecting routine items, such as antibiotic prophylaxis and sponge, instrument, and needle counts.

    “Use of a checklist reduces the chance of neglecting routine items, such as antibiotic prophylaxis and sponge, instrument, and needle counts.”
  • The paper relies on this without support.

    Performing a checklist during and after a surgical procedure enhances communication between team members and gives all participants a chance to speak up if something appears to have been overlooked.

    “Performing a checklist during and after a surgical procedure enhances communication between team members and gives all participants a chance to speak up if something appears to have been overlooked.”
  • The authors state this as an assumption.

    Only the anesthesiologist and L&D nurse will perform the briefing, whereas the time-out requires the presence of the entire operating team.

    “We assume that only the anesthesiologist and L&D nurse will perform the briefing, whereas the time-out requires the presence of the entire operating team.”
7 of 7

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Thromboembolism checklist cites an unrelated guideline

    Minor

    The text identifies reference 17 as an SMFM venous-thromboembolism checklist, but reference 17 is an enhanced-recovery guideline. The named SMFM checklist appears at reference 16.

  • SMFM guidance points to a Council reference

    Minor

    Citation 15 follows the mention of SMFM guidance, but reference 15 is a Council on Patient Safety toolkit. The SMFM publication is reference 14.

  • Council guidance points to an SMFM reference

    Minor

    The Council guidance is cited as reference 16, but reference 16 is an SMFM statement on thromboembolism prophylaxis. The Council toolkit is reference 15.

  • Leape's quotation is assigned to another author's reference

    Minor

    The text attributes the quotation to Leape with citation 11, but reference 11 lists Conley and colleagues. Leape is listed as reference 10.

4 of 4

Cites

Flagged first, then by citations

Cited by

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Authors
Combs, C. A., Einerson, B. D., & Toner, L. E.
Affiliations
Society for Maternal-Fetal Medicine (US)
Venue
American Journal of Obstetrics and Gynecology
Publisher
Elsevier BV
Published
2021-11
Volume
225
Issue
5
Pages
B43-B49
ISSN
0002-9378 (ISSN-L)
OpenAlex
W3184354066
Cited by
12
References
18
Citations by year
2026: 4 · 2024: 5 · 2023: 1 · 2022: 2
FWCI
2.44
Type
journal article
Language
en
Open access
Locations
  • American Journal of Obstetrics and Gynecology (publishedVersion)
  • PubMed (publishedVersion)
Funders
Society For Maternal-Fetal Medicine
Topics
  • Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
  • Health Sciences › Medicine › Obstetrics and Gynecology › Maternal and Perinatal Health Interventions
  • Health Sciences › Medicine › Surgery › Surgical site infection prevention
Keywords
surgical safety checklist, cesarean section, patient safety, perioperative complications, care coordination, neonatal care, emergency cesarean section, preoperative checklist, checklist implementation, maternal-fetal care
MeSH terms
Cesarean Section, Emergencies, Female, Humans, Infant, Newborn, Operating Rooms, Postoperative Complications, Pregnancy, Program Development, Elective Surgical Procedures, Checklist, Patient Safety

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